Perioperative Antiplatelet Bridging With Cangrelor: A Cohort Study and Narrative Review

Abstract

Background: In patients who received a cardiac stent, practice guidelines recommend dual antiplatelet therapy (DAPT). However, an urgent procedure may be required necessitating interruption of DAPT. Intravenous cangrelor was previously shown to be an alternative due its short-half life and quick onset/offset. Objective: To determine the safety and effectiveness of cangrelor bridging for patients undergoing invasive procedures in a veteran population. Methods: Retrospective cohort of patients from Michael E. DeBakey VA Medical Center and the VA North Texas Health Care Systems who underwent perioperative cangrelor bridging. The primary outcome was the incidence of bleeding using the Bleeding Academic Research Consortium (BARC) criteria. The secondary outcome was a composite of nonfatal stroke, myocardial infarction (MI), mortality, and unplanned revascularization within 30 days. A narrative review was also performed to summarize cangrelor bridging for noncardiac invasive procedure. Results: There were 41 patients that met the eligibility criteria. Patients were predominantly Caucasian (57.5%) men with a median age of 70 years. The median duration on cangrelor bridging was 2.6 days with 11 and 30 patients undergoing cardiac and noncardiac invasive procedures, respectively. Nine patients (22%) had a bleeding event of which 8 were minor. One was severe due to significant iliopsoas hematoma following drain placement. All bleeding events occurred postoperatively except for 2 perioperative events that occurred during orthopedic procedures. Ischemic events up to 30 days occurred in 3 patients (7.3%) which consisted of 1 (2.4%) nonfatal MI requiring revascularization and 2 (4.9%) deaths, 1 of which was sudden cardiac. Conclusion and Relevance: This study suggests that cangrelor bridging may be a reasonable alternative to holding oral P2Y12 inhibitors in patients requiring interruption of antiplatelet therapy for an urgent surgery/invasive procedure.

Platelet Function Testing to Guide Cangrelor Dosing in Patients with Temporary Mechanical Circulatory Support or as a Bridge to Procedure

“…Several previous studies in patients supported with VA-ECMO or as bridging therapy used empiric cangrelor dosing of 0.75 mcg/kg/min based on similar dosing used in the BRIDGE trial. 4 , 5 , 7 – 11 Other studies allowed for lower cangrelor doses between 0.5 and 0.75 mcg/kg/min 12 , 13 with PRU monitoring or empiric dosing as low as 0.125 mcg/kg/min in one study of patients supported on VA-ECMO. 6 In our study, we utilized an initial dose of 0.75 mcg/kg/min with subsequent dose adjustments based upon PRU values.…”

“…Previous studies have evaluated the off-label use of low dose cangrelor in patients requiring temporary mechanical circulatory support (MCS) or in bridging cases before surgery or a procedure. 4 – 14 Additionally, small case series have assessed using platelet function testing (PFT) with the VerifyNow P2Y12 assay to guide cangrelor dosing in bridging situations or in patients with temporary MCS; however, these previous studies lacked a standardized protocol for dose adjustments based upon P2Y12 reaction units (PRU) and utilized different goal values for PRU. 12 – 14 Therefore, additional studies are needed to better evaluate the clinical utility of PFT to guide cangrelor dosing.…”